Dec 20, 2016
Open for Business-Part 2
Dr. Mark Timmons

Unique sports medicine clinics are popping up across the country, and Marshall University is home to two such facilities. Last week, we examined how the Marshall University Sports Medicine Institute takes a comprehensive approach to care. This week, we take a look at how the Center for Wellness in the Arts (CWA) addresses an underserved population.


The patients seen at our clinic practice daily and perform in highly competitive environments. They often suffer musculoskeletal injuries, which can sideline them for weeks or months. When these injuries start to severely hamper performance, the patients may be forced to retire. Sounds like I’m talking about athletes, doesn’t it? I’m actually referring to the musicians, dancers, and actors who receive treatment through the CWA at Marshall University.

Performing artists have unique health and wellness needs dictated by their creative pursuits. However, this population has long been underserved by medical professionals due to a lack of understanding surrounding the mechanisms of their injuries.

In the summer of 2014, two faculty members from Marshall’s College of Arts and Media (CAM) set out to change this. Nicole Perrone, Associate Professor of Acting and Movement, and Henning Vauth, DMA, Assistant Professor of Piano and Coordinator of Keyboard Studies, both experienced injuries and other health issues during their performing careers, and they didn’t want their students to develop similar problems.

For this reason, they reached out to me and other instructors from the College of Health Professions (COHP) to brainstorm how to bring quality medical care to performing artists. Because my colleagues and I immediately saw the overlap between treating artists and athletes, we were happy to collaborate.

From there, we started to lay the groundwork for what would become the CWA. We envisioned a comprehensive, multidisciplinary program exclusively for performing artists. It would stand out by offering services in the fields of athletic training, nutrition, communication disorders (speech and hearing), psychology, and exercise science.

Music and acting students used the [athletic training] clinic in equal numbers. Most of the injuries we treated were categorized as muscle/tendinous strains, with a few ligamentous sprains, and we saw a number of chronic hand and arm injuries — likely associated with the playing of musical instruments.

We wanted the CWA to be about more than treatment, however. It also had to contribute to the academic and professional development of the students and faculty of the CAM and COHP. Therefore, we established three pillars to guide our planning of the program: education, clinical services, and research.

Once we had a pretty good idea of what we wanted the CWA to be and do, our next priority was finding a space to provide services. Since we received no extra funding for the CWA, we had to use existing sites on campus. We quickly determined that consults for nutrition, communication disorders, psychology, and exercise science could be provided at the COHP’s existing clinics and labs.

For our dedicated athletic training facility, we initially wanted to use the athletic department’s athletic training rooms. Unfortunately, they were already at full capacity, so that was a no-go. We turned next to the teaching laboratory used by the Athletic Training Program in the School of Kinesiology. It was equipped with several treatment tables, e-stim and ultrasound machines, and tons of other rehab tools. The School of Kinesiology agreed to let us use the space from 4 to 6 p.m., Monday through Friday, as that time frame would not interfere with classes using the lab.

After finding a site for the CWA’s athletic training clinic, we shifted our focus to staffing. While licensed audiologists, dietitians, clinical psychologists, and exercise scientists from the COHP were willing to offer their services as needed, we wanted the CWA to have its own dedicated athletic trainer. It couldn’t just be any athletic trainer, however. Because we didn’t have a budget to fund a full-time position, we needed a graduate athletic training student. He or she also had to have experience working with performing artists and a desire to continue on that path.

The candidate we ultimately chose, Elliot Smithson, ATC, had spent time treating performing artists at Walt Disney World in Orlando, Fla., and he expressed an interest in pursuing an athletic training career with this population. Once on board, he began graduate studies at Marshall and recently completed his master’s degree in athletic training.

With the logistics of the CWA wrapped up, we prepared to launch the program at the beginning of the fall 2014 semester. To spread the word to Marshall’s performing arts community, we included announcements about the CWA in pre-semester meetings with the CAM and COHP faculty. Students were informed via presentations made during the Music 101 course (which is taken by all freshman music majors), entry-level theater classes, and at theater preproduction organizational meetings. Our involved CAM instructors also distributed educational materials about performance anxiety, hearing and vocal health, and pre-performance warm-ups in their classes and explained how the CWA could address these issues. Furthering our cause to a broader audience, we announced the CWA’s opening on Marshall’s website and created a Facebook page and Twitter account for the program.

Our final promotional step was inviting Eckart Altenmuller, MD, PhD, to Marshall for a series of academic lectures to the COHP, CAM, School of Medicine, and Department of Orthopaedics. Combining his skills as a trained neurophysiologist and classical flutist, Dr. Altenmuller serves as Director of the Institute of Music Physiology and Musicians’ Medicine in Hanover, Germany. We planned his lectures to coincide with the opening of the CWA and advertised both events across campus.

The CWA officially kicked off in October 2014. Afterward, our faculty from nutrition, communication disorders, psychology, and exercise science wasted no time meeting with students as needed.

As for athletic training, music and acting students used the clinic in equal numbers. Most of the injuries we treated were categorized as muscle/tendinous strains, with a few ligamentous sprains, and we saw a number of chronic hand and arm injuries — likely associated with the playing of musical instruments. Elliot provided the majority of the athletic training services, and I assisted when it was busy and provided faculty mentorship.

In addition to the services provided in the clinic, Elliot attended rehearsals for several of the music and theater shows. During these times, he led physical warm-up sessions and provided injury evaluation and treatment for performers who couldn’t make it to the scheduled clinic hours.

Any patients seen by Elliot who needed further evaluation by a physician were referred to the Marshall Sports Medicine Institute or the patient’s personal physician. Emergency cases were transported to Cabell Huntington Hospital and followed up through the Marshall Student Health Center.

During the CWA’s first year, 299 contacts occurred in the athletic training clinic. Ninety-seven of those were initial evaluations and treatments, while the remaining 202 were follow-up visits. This ratio suggests that most of the patients returned to the clinic at least once, which we were thrilled to see.

Although the user statistics for the first year were encouraging, we expected them to be higher. When we analyzed the data, it revealed we were struggling to get consistent visits at the athletic training clinic. Usage would spike when we held an information session about the facility, but then attendance would decrease over time. One contributing factor to this was our location, which is not near the CAM. The future success of our program will depend on our ability to better inform performing arts students of our services. Data for the athletic training clinic’s second year is currently under analysis, but we think we expanded our total number of contacts.

Another challenge we faced in our inaugural year was the lack of knowledge performing artists had about athletic trainers. Most athletes know what we are and what we do, but our CAM students were completely in the dark about what we could offer.

This was very obvious when the issue of concussions arose. By now, most athletic organizations have concussion protocols, but that’s not the case in the world of performing arts. For example, a CAM student received a blow to the head in a rehearsal soon after the CWA started. Elliot diagnosed the student with a concussion, and we had to explain return-to-activity and return-to-learn plans to all involved.

Beyond all our clinical offerings, the CWA fulfilled our research pillar by fostering an investigative collaboration between the COHP and CAM. When we started, the CAM faculty had questions about injuries sustained by performing artists. Over the past two years, the COHP faculty has been searching for the answers while broadening their own horizons.

For instance, at the 2015 Performing Arts Medical Association meeting, Elliot and I presented the results of a study investigating the subacromial space and the supraspinatus tendon in violin players. We found that the arm postures common to playing the violin result in a reduced width of the subacromial space, which has been associated with the development of rotator cuff disease. I have been investigating the relationship between arm motion and shoulder injury for years, but the CWA allowed me to expand my line of research and better understand the mechanisms leading to musculoskeletal shoulder pain.

Other topics under investigation in the CWA include the effects of endurance exercise on dance performance, strength and proprioceptive training on stage combat performance, voice training on singing and stage performance, and the treatment and quantification of performance anxiety in stage actors. These are all in the early stages of data collection.

Since its founding, a lot of people have asked me about the secret to the CWA’s success. For starters, I think the strong collegial relationship between the administrators and faculties of the CAM and COHP has helped the program to flourish. The lack of a budget forced us to pool our resources and concentrate on doing what we could with what we had. Besides using the athletic training teaching lab for our athletic training clinic, the exercise science faculty employed techniques normally used in improving athletic performance to enhance the exercise tolerance of stage performers, while the School of Communication Disorders used hearing screenings for music students to create a learning experience for audiology students.

The absence of a typical hierarchical organizational structure also allowed each discipline within the CWA to grow according to the desire of the involved faculty. This permitted professors to provide services that were unique to the disciplines of the CAM students.

Other schools that are thinking of starting a similar health and wellness program for performing artists are welcome to follow our model. But before doing so, they should first assess their campus’ need for the service, as well as their capacity to provide it. Lastly, they should understand that undertaking something as broad as the CWA is a collaborative effort, and everyone involved should participate according to their strengths.

Despite its occasional obstacles, the CWA has reached its goal of providing much needed medical care for performing arts students, and we hope it continues to grow. Athletes are already accustomed to working with athletic trainers and will seek assistance for their injuries. As the CWA becomes more established, we expect Marshall performing artists to develop the same relationship with the athletic training profession.

This article first appeared in the July/August 2016 issue of Training & Conditioning.

Mark Timmons, PhD, ATC, is an Assistant Professor of Athletic Training in Marshall University's College of Health Professions. He can be reached at: [email protected].

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